Nurs 327: Exam 1

The wife of a client is concerned because her husband is requiring increasingly high doses of analgesia. She states, "He was in pain long before he got cancer because he broke his back about 20 years ago. For that problem, though, his pain medicine wasn't just raised and raised." What would be the nurse's best response?

"Much cancer pain is caused by tumor involvement and needs to be treated in a way that brings the client relief."

The nurse is teaching students about the West Nile virus. Which statement by the nurse is accurate?

"There is no treatment for West Nile virus infection."

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?

<30 mL

The circulating nurse must be vigilant in monitoring the surgical environment. Which of the following actions by the nurse is inappropriate?

Allow unnecessary personnel to enter the OR environment.

Which is an insensible mechanism of fluid loss?

Breathing

A client reports tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the client's laboratory work has returned?

Calcium

What action by the nurse best encompasses the preoperative phase?

Educating clients on signs and symptoms of infection

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?

Increases arterial pH

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?

Ineffective thermoregulation

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?

Instruct the client to breathe into a paper bag.

The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply.

Listening to music Watching television Changing position

A client is undergoing a perineal surgical procedure. The nurse should place the client in which position?

Lithotomy

Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective?

Vital signs within normal limits; absence of chills and cough

Which of the following medications would the nurse expect to be used to facilitate intubation of the client?

atracurium (Tracrium)

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

auscultate bowel sounds.

The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated.

b. 5% DW

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer:

dantrolene sodium (Dantrium)

The nurse recognizes the client has reached stage III of general anesthesia when the client:

lies quietly on the table

A client is recovering from abdominal surgery. The statement by the client that most indicates the nurse needs to educate the client about pain and pain control is

"I should expect to have pain."

After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements?

"I'll be sleepy but able to respond to your questions."

A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?

"It assists in preventing infection

A client who is scheduled for knee surgery is anxious about the procedure, saying, "You hear stories on the news all the time about doctors working on the wrong body part. What if that happens to me?" What is the nurse's best response? Select all that apply.

"The client can be involved in marking the knee, the site for the surgery." "The surgical team performs a 'time-out' prior to surgery to conduct a final verification." "The client will be involved in the verification process prior to surgery."

A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse?

"The lungs primarily eliminate the anesthesia."

Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?

"When is the last time you ate or drank?"

When developing a teaching plan for a patient scheduled for ambulatory surgery with epidural anesthesia, which of the following would the nurse include?

"You shouldn't experience a headache after this type of anesthesia."

The nurse is providing education to a client who has been diagnosed with trichomoniasis. When providing information about metronidazole, what should the nurse be certain to include?

"You will need to avoid alcohol during treatment and for 3 days after the medication is complete."

A client weighing 160.2 pounds (72.7 kg), who has been diagnosed with hypovolemia, is weighed every day. The health care provider asked to be notified if the client loses 1,000 mL of fluid in 24 hours. What weight would be consistent with this amount of fluid loss?

158.0 lbs (71.7 kg)

Which stage of surgical anesthesia is also known as excitement?

2

The nurse is triaging surgical clients. Which client would the nurse document as in need of urgent surgical care?

A client with an acute gallbladder infection

The nurse expects informed consent to be obtained for insertion of:

A gastrostomy tube

A client with hypervolemia asks the nurse what mechanism in the sodium potassium pump will move the excess body fluid. What is the nurse's best answer?

Active Transport

The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply.

An elevated hematocrit level Electrolyte imbalance

Which nursing diagnosis should the nurse plan to address first in the client upon arrival in the intraoperative setting?

Anxiety related to ineffective coping with surgical concerns

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes?

Blood pressure of 90/50 mm Hg

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?

Chest Pain

The nurse is caring for a group of clients at a public health clinic. Which sexually transmitted disease would the nurse focus the client education on curative goals?

Chlamydia

The nurse is providing care to a client who has been diagnosed with gonorrhea. The nurse also prepares the client for treatment of which of the following?

Chlamydia

A nurse is preparing to insert a peripheral intravenous access device into the arm of a client. When preparing the skin for insertion, which of the following should the nurse use to prevent possible health-care associated bloodstream infections?

Chlorhexidine

Which electrolyte is a major anion in body fluid?

Chloride

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented?

Circulating nurse

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities?

Coordinating the surgical team

Which of the following actions by the nurse is appropriate?

Discarding an object that comes in contact with the 1-inch border

The nurse is monitoring a presurgical patient for electrolyte imbalance. Which classification of medication may cause electrolyte imbalance?

Diuretics

Informed consent from the surgical client is essential in all of the following categories of surgery except:

Emergent surgery

When integrating the principles for maintaining surgical asepsis during surgery, which of the following would be most appropriate?

Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

First Intention

A client who has developed a painless penile ulcer is diagnosed with syphilis. What treatment would physician prescribe?

IV penicillin G; single dose

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which?

Insensible fluid loss

A client asks about the purpose of withholding food and fluid before surgery. Which response by the nurse is appropriate?

It prevents aspiration and respiratory complications.

As a circulating nurse, what task are you solely responsible for?

Keeping records.

With which condition should the nurse expect that a decrease in serum osmolality will occur?

Kidney failure

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Lactated Ringers solution

Corticosteroids have which effect on wound healing?

Mask the presence of infection

The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for?

Metabolic Acidosis

The nurse is conducting a preoperative assessment on a client scheduled for gallbladder surgery. The client reports a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung, with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 (taken orally), heart rate is 87, and blood pressure is 124/70. What is the best action by the nurse?

Notify the surgeon to possibly delay the surgery.

A patient is scheduled for surgery with spinal anesthesia. When explaining this type of anesthesia to the patient, which body area would the nurse describe as being affected first?

Perineum

The nurse has administered preanesthetic medication. What action should the nurse take next?

Place the client on bed rest with the side rails up.

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?

Pneumonia

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse?

Position the client in the side-lying position.

Which electrolyte is a major cation in body fluid?

Potassium

The 5 P's of sexual history

Prevention, practice, protection, partners, and past history

The nurse is attempting to ambulate a client who underwent shoulder surgery earlier in the day, but the client is refusing to do so. What action by the nurse is most appropriate?

Reinforce the importance of early mobility in preventing complications.

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing the dressing or applying pressure if bleeding is frank

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

Respiratory acidosis

A client receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first?

Roll the client onto his or her side.

Which of the following stimulates the wound healing process?

Sufficient oxygenation

A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member?

Surgeon

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?

The Hemovac drain isn't compressed; instead it's fully expanded.

The patient is NPO prior to having a colonoscopy. The patient is to take a daily blood pressure pill prior to the procedure. Until when may water be given prior to the procedure?

Up to 2 hours before surgery

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing?

Wound infection

A client with emphysema is at a greater risk for developing which acid-base imbalance?

chronic respiratory acidosis

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation.

The nurse is analyzing the arterial blood gas (ABG) results of a client diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis?

pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L

A client is undergoing a surgical procedure to repair an ulcerated colon. Which client education topics will be discussed preoperatively? Select all that apply.

postoperative pain control cough and deep-breathing exercises intravenous fluids and other lines and tubes

Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency?

Adrenal

A fractured skull would be classified under which category of surgery based on urgency?

Emergent

A gunshot wound would be classified under which category of surgery based on urgency?

Emergent

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

Evisceration

A nurse would implement droplet precautions for a client with which condition? Select all that apply.

Pertussis Mumps Parvovirus B 19

A nurse is caring for a client who is scheduled to have a thoracotomy. When planning care for this client, what mobility teaching will the nurse include in the plan of care?

Shoulder and upper arm range-of-motion exercises

Which of the following techniques least exhibits surgical asepsis?

Suctioning the nasopharyngeal cavity of a client

How does the nurse determine that the patient may have hidden fears about the impending surgical procedure? (Select all that apply.)

The patient avoids communication with the nurse. The patient repeatedly asks questions that have previously been answered. The patient talks incessantly.

A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching?

Tingling sensation in the fingers

The nurse is caring for a postsurgical client who speaks very little English. How should the nurse most accurately assess this client's pain?

Use a chart with English on one side of the page and the client's native language on the other so he can rate his pain.

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering?

0.45% NaCl

The physician schedules an elective surgical procedure for a patient who smokes cigarettes. When should the nurse recommend that the patient cease smoking before the surgical procedure to minimize risks associate with cigarette smoking?

1 to 2 months

A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client's pH value to be

7.50

What is the blood glucose level goal for a diabetic client who will be having a surgical procedure?

80 to 110 mg/dL

To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care?

Assist with oral fluid intake.

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.)

Assisting the patient with leg exercises Encouraging early ambulation Avoiding placement of pillows or blanket rolls under the patient's knees

Which action by the nurse indicates understanding of one basic principle of providing effective pain management?

Awakening a new postoperative client to take pain medication

A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What's the drug of choice for treating legionnaires' disease?

Azithromycin (Zithromax)

What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound?

Count the sponges.

The nurse is assessing a postoperative patient's abdominal wound and observes a portion of intestines protruding through the wound. What is the priority intervention for the nurse to provide?

Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.

The nurse is caring for a 72-year-old client who has been admitted to the unit for a fluid volume imbalance. The nurse knows which of the following is the most common fluid imbalance in older adults?

Dehydration

The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered?

Denies sensation to perineum and lower abdomen

The nurse is caring for a client with a serum potassium concentration of 6.0 mEq/L (6.0 mmol/L) and a fluid volume excess. The client is ordered to receive oral sodium polystyrene sulfonate and furosemide. What other order should the nurse anticipate giving?

Discontinue the IV lactated Ringers solution

Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?

Elevated hematocrit level

A nurse is preparing a presentation for a local community group in a small rural area about hantavirus pulmonary syndrome. Which of the following would the nurse suggest as a major prevention strategy?

Eliminating rodent food sources in areas near humans

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia

The patient is having a repair of a vaginal prolapse. What position does the nurse place the patient in?

Lithotomy position

The nurse is seeing a client in the community health clinic who reports finding "sores" in the mouth. On assessment, the nurse notes the lesions appear flat, flesh colored and papillary. What should the nurse do next?

Obtain a health history that includes inquiring about sexual health practices

What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site?

Obtain the attention of all members of the surgical team.

A postoperative client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate?

Obtain the wound culture specimen.

The nurse recognizes that written informed consent is required for insertion of a(n):

Peripherally-inserted central catheter.

Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?

Physician

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

Position the client in Fowlers position. Don sterile gloves. Lubricate the sterile suction catheter. Insert suction catheter into the lumen of the tube. Apply intermittent suction while withdrawing the catheter.

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation.

What complication is the nurse aware of that is associated with deep venous thrombosis?

Pulmonary embolism

When assessing a client with infectious diarrhea, which of the following would lead the nurse to suspect that the client is experiencing severe dehydration?

Rapid, thready pulse

The client is postoperative for a right total-knee arthroplasty, and medications include lidocaine 5% (Lidoderm). Past history includes a left mastectomy and herpes zoster following treatment with chemotherapy. The best nursing action is to:

Remove the patch after 12 hours.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?

Serum sodium level of 124 mEq/L Explanation: In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.

Nursing students are reviewing information about sexually transmitted infections (STIs). They demonstrate a need for additional review when they identify which of the following as an example?

Shigella

When does the nurse understand the patient is knowledgeable about the impending surgical procedure?

The patient participates willingly in the preoperative preparation.

Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)?

Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad

A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia?

To prevent cerebrospinal fluid (CSF) leakage

The nurse is educating a community group about types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true?

Tumor excision

A client vomits postoperatively. What is the most important nursing intervention?

Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.

A patient begins to vomit during surgery. Place the actions below in the order in which they would be performed.

Turn the patient to the side. Lower the head of the surgical table. Provide a basin for collection. Suction to remove saliva.

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?

Urine retention

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing.

A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse?

Verify consent.

How often should women diagnosed with human papillomavirus (HPV) have Pap smears?

Yearly

A term used to describe a partial or complete separation of wound edges is

dehiscence.

A nurse evaluates the potential effects of a client's medication therapies before surgery. Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia?

diuretics

What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block?

"Remain supine for the time specified by the physician."

A client asks the nurse about possible ill effects from general anesthesia. What is the best response by the nurse?

"Some possible negative effects include difficulty waking up and slow heart rate."

The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room?

7

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance?

A 52-year-old with diarrhea

A patient is scheduled to have a heart valve replacement with a porcine valve. Which patient does the nurse understand may refuse the use of any porcine-based product?

A patient of Jewish faith

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mm Hg

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action?

Call the health care provider.

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

Central venous pressure

The nurse is caring for a young adult client with a diagnosis of cerebral palsy who has been admitted for the relief of painful contractures in his lower extremities. When creating a nursing care plan for this client, what variables should the nurse consider? Select all that apply.

Client's comorbid conditions Type of procedure be performed Changes in neurologic function due to the procedure Prior effectiveness in relieving the pain

Which of the following describes microorganisms present without host interference or interaction?

Colonization

Which term refers to a state of microorganisms being present within a host without causing host interference or interaction?

Colonization

The nurse recognizes what groups of people are at an increased risk for infection? Select all that apply.

Debilitated clients Older adults Clients with impaired skin

At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period?

During the preoperative period

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?

Elevated blood pressure

A nurse asks a client who had abdominal surgery 1 day ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?

Encourage the client to ambulate as soon as possible after surgery.

The nurse is caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?

Encourage the client to move legs frequently and do leg exercises.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

First intention

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by:

First intention

Which of the following is the most effective treatment for trichomoniasis?

Flagyl

A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed?

Furosemide

Which factor increases blood urea nitrogen (BUN)?

Gastrointestinal bleeding

After teaching a group of students about sexually transmitted infections (STIs), the instructor determines that additional teaching is necessary when the students identify which STI as curable with treatment?

Genital Herpes

The nurse is presenting a community lecture about STIs, and emphasizes that some STIs are easily cured with early and adequate treatment. Which is not among these easily treated diseases?

Genital Herpes

Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic?

Halothane

A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for?

Hypoglycemia

An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?

Hypokalemia

A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention?

Mask is placed over nose and extends to bottom lip.

During surgery a patient develops hypothermia. The circulating nurse would monitor the patient closely for which of the following?

Metabolic acidosis

A client is being prepared for a same-day surgical procedure and is discussing with the nurse what potential ramifications this type of surgery has. Which of the following would the nurse correctly identify? Select all that apply.The client will leave the hospital sooner than in the past.

Need for teaching is increased. The client must be prepared to take on more self-care than he or she may have done in the past.

A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action?

Notify the surgeon.

An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position?

On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle

Which is a correct route of administration for potassium?

Oral

A client is scheduled for a cholecystectomy. Which finding by the nurse is least likely to contribute to surgical complications?

Osteoporosis

Which of the following is the medication of choice for early syphilis?

Penicillin G benzathine

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?

Pink to red and soft, noting that it bleeds easily

A nurse implements aseptic technique as a means to break the chain of infection at which element?

Portal of entry

The nurse is caring for a client needing emergency surgery. Which preoperative teaching is least important to prepare the client for surgery?

Post-discharge diet

Which route of medication administration should the nurse consider first after IV removal in a postoperative client with an NPO (nothing by mouth) order?

Rectal

The nurse is providing an education program to reduce the incidence of infection currently on the rise in the community. What areas should the nurse focus on when presenting this program? (Select all that apply.)

Regulated health practices Sanitation techniques Immunization programs

A client is preparing to undergo a curative surgical procedure. Which of the following is the type of surgery the client could be having? Select all that apply.

Removal of a tumor Removal of a diseased appendix

A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply.

Reorient the client. Assess for hypoxia. Assess urine output.

A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse?

Report the infection to an immediate supervisor.

A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?

Request that the surgeon come and answer the questions.

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory alkalosis

Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?

Review the scheduled procedure, site, and client.

A 55-year-old patient arrives at the operating room. The nurse is reviewing the medical record and notes that the patient has a history of osteoporosis in her lower back and hips. The patient is scheduled to receive epidural anesthesia. Which of the following nursing diagnoses would be a priority for this patient?

Risk for perioperative positioning injury related to operative position

The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure?

Risk for perioperative positioning injury related to positioning in the OR

A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role?

Scrub Role

A nurse is working as part of the surgical team in the semi-restricted area. Which of the following would be appropriate to wear? Select all that apply.

Scrub clothes Caps

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?

Sodium

There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements

Stage II: excitement

Which organism is responsible for impetigo?

Staphylococcus aureus

Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern?

Surgeon

The nurse is caring for a client diagnosed with hyperchloremia. Which are signs and symptoms of hyperchloremia? Select all that apply.

Tachypnea Weakness Lethargy

What clinical indication of hyperphosphatemia does the nurse assess in a patient?

Tetany

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?

The client can be discharged from the PACU.

A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia?

The client can develop malignant hyperthermia up to 24 hours after surgery.

A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize?

The edges of a sterile package, once opened, are considered unsterile.

The physician requests lidocaine 2% with epinephrine for use in local infiltration anesthesia. What does the nurse understand is the purpose of adding epinephrine to the lidocaine? (Select all that apply.)

The epinephrine causes vasoconstriction. The epinephrine prevents rapid absorption of the anesthetic drug. The epinephrine prolongs the local action of the anesthetic agent.

Which intervention should the nurse implement during the intraoperative period to protect the client from injury? Select all that apply.

Verify scheduled procedure with client. Assess the client for allergies. Confirm the consent form is signed.

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client?

experiences pain within tolerable limits.

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication?

malignant hyperthermia

A client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which acid-base imbalance?

metabolic alkalosis

The six elements necessary for infection include a causative organism, a reservoir of available organisms, a portal or mode of exit from the reservoir, a mode of transmission from reservoir to host, a susceptible host, and

mode of entry into the host

Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?

osmosis

A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia?

oxygen

Which findings would be indicative of a nursing diagnosis of decreased cardiac output?

tachycardia; hemoglobin 10.9 gm/dL; BP 88/56

A 78-year-old client is undergoing surgery to repair a right hip fracture. What nursing action is appropriate during the intraoperative phase?

Appropriately position the client using adequate padding and support.

A nurse knows that she must obtain a signed informed consent for which of the following procedures? Select all that apply.

Arteriography Open reduction of a fracture Cystoscopy Paracentesis

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client?

An isolation room three doors from the nurses' station

Which of the following is the most common cause of symptomatic hypomagnesemia in the United States?

Alcoholism

In preparing the client for transfer to the operating room, which of the following actions by the nurse is inappropriate?

Allow pt to wear dentures

The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance?

An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide.

The nurse should determine that a client is coughing effectively after surgery if the nurse observes which of the following activities?

The client takes a deep abdominal breath and then "huff" or "hack" coughs three or four times.

The nurse is assessing a client who reports stiff joints and alopecia. While taking the client's health history, the client reports having multiple sexual partners in the past 6 months and finding a lesion on her labia about 1 month before today's appointment. What should the nurse anticipate based on the signs and symptoms presented?

The client will require treatment for the secondary stage of syphilis.

You work on a long-term care unit. In the last two weeks more than half the clients on your unit have been diagnosed with gastroenteritis. What is the most likely reason?

The infection is being transmitted by healthcare personnel.

A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate?

You will be lying on your side with your knees to your chest."

A client with syphilis is to receive penicillin G benzathine 1.2 million units IM as a single dose. The pharmacy supplies the medication, which is labeled as 2.4 million units/4 mL. How many milliliters would the nurse administer? Enter the number ONLY.

2

Which intervention should a nurse perform after administering an injection of penicillin to a client with an infection?

Make the client wait at least 30 minutes before leaving

The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?

Temperature of 102.5°F (39°C)

A nurse is teaching a client about diaphragmatic breathing. What client action indicates that further teaching is needed?

The client exhales forcefully with a short expiration.

Which statement by the client indicates further teaching about epidural anesthesia is necessary?

"I will become unconscious."

A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?

"I will support my incision with my hands when I cough and do my deep breathing exercises."

The nurse is talking to a client who has come to the doctor's office to ensure that the client's sexually transmitted infection (STI) has been successfully treated. Which statement by the client requires further instruction?

"It's great that I don't have to worry about having this infection again because I'm now immune to it."

Which nursing statement would best decrease a client's anxiety before an emergency operative procedure?

"Let me explain to you what will happen next."

You are the nurse working in an ambulatory surgery center. A teenage son of your clients ask you why so many people have surgery. What would be your best reply?

"Many people have diagnostic or short therapeutic surgical procedures."

The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed?

"The nurse will explain the details of the surgery before I sign a consent."

For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery?

7

A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery?

7 to 10 days

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:

Circulating nurse

A nurse is planning preoperative teaching for an older client. Which structural or functional changes in the older adult impact the surgical experience? Select all that apply.

Increased fatty tissue prolongs elimination of anesthesia. Decreased ability to compensate for hypoxia increases the risk of an embolism. Loss of collagen increases the risk of skin complications. Reduced tactile sensitivity can lead to assessment and communication problems.

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?

The client is displaying early signs of shock.

A nurse has heard that there have been three cases of pertussis in the community and wants to make sure his or her inoculations are up to date. What action should the nurse take?

Have a single-dose Tdap administered.

The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching?

Headache

The nurse recognizes which symptom as a clinical manifestation of shock?

Rapid, weak, thready pulse

The circulating nurse is unsure whether proper technique was followed when an object was placed in the sterile field during a surgical procedure. What is the best action by the nurse?

Remove the entire sterile field from use.

The nurse recognizes that the client who takes hydrochlorothiazide to manage hypertension is predisposed for which interaction with anesthesia?

Respiratory depression

The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to:

Respond verbally during the procedure

A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?

Splint the incision site using a pillow during deep breathing and coughing exercises

A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse:

continuously monitors the sedated client.

A physically fit older adult is scheduled for right knee replacement. What factor for the client creates an increased risk for postoperative complications?

current smoking history

The nurse recognizes that the older adult is at risk for surgical complications due to:

decreased renal function

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as

emergency.

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply.

nutritional status age physical condition health status

The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which laboratory value would be of greatest concern to the nurse?

potassium 6.2 mEq/L